General Practice as an Integral Part of the Health System

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1General Practice as an Integral Part of the Health System09 Copenhagen general practice May3/23/2017General Practice as an Integral Part of the Health SystemBarbara Starfield, MD, MPH16th Nordic Conference on General PracticeCopenhagen, DenmarkMay 13-16, 20091

2Life Expectancy Compared with GDP per Capita for Selected Countries09 Copenhagen general practice May3/23/2017Life Expectancy Compared with GDP per Capita for Selected CountriesCountry codes:AG=ArgentinaAU=AustraliaBZ=BrazilCH=ChinaCN=CanadaFR=FranceGE=GermanyHU=HungaryIN=IndiaIS=IsraelIT=ItalyJA=JapanMA=MalaysiaME=MexicoNE=NetherlandsPO=PolandRU=RussiaSA=South AfricaSI=SingaporeSK=South KoreaSP=SpainSW=SwedenSZ=SwitzerlandTK=TurkeyTW=TaiwanUK=United KingdomUS=United StatesThis graph shows the well-known relationship between country wealth (as expressed by GDP per capita) and life expectancy. Although not previously stressed, it shows considerable variation in life expectancy at any given GDP. For example, Poland and South Africa have approximately similar wealth but life expectancy is, on average, 7-8 years greater in Poland. Variability is noted all along the curve, even at its asymptotic end, as some countries at the wealthy end of the curve experience lower life expectancy than less wealthy countries. These include, particularly, Switzerland and the US. Other wealthy countries fall below the curve; these include Germany, Taiwan, and Singapore. Thus, wealth alone does not assure health. The graph also shows a new phenomenon: an apparent decline in life expectancy above a certain level of country wealth. Some very wealthy countries (US, Switzerland) are recently experiencing lower life expectancy than some less wealthy countries, and some others (Germany, Singapore, Taiwan) are below the curve. That is, they have lower life expectancy than expected despite their wealth. These five countries are all countries whose health systems are more specialty oriented than primary care oriented, suggesting the likelihood that there is excessive and unnecessary specialty and technology use leading to inappropriate care and perhaps even an increasing rate of adverse effects from excessive intervention.Source: Economist Intelligence Unit. Healthcare International. 4th quarter London, UK: Economist Intelligence Unit, 1999.Source: Economist Intelligence Unit. Healthcare International. 4th quarter London, UK: Economist Intelligence Unit, 1999.Starfield 11/06IC 3493 n2

3Country* Clusters: Health Professional Supply and Child Survival09 Copenhagen general practice May3/23/2017Country* Clusters: Health Professional Supply and Child SurvivalDensity (workers per 1000)Child mortality (under 5) per 1000 live births359501002502515105.02.51This slide shows the well-known direct relationship between the density of health professionals and one aspect of the health of populations: health professional supply. As this slide shows, the relationship holds only on average, and there is considerable variation, with some countries having many health workers but still relatively high child mortality under age 5. There is even one country with few health workers that has a child mortality the same as the United States and Cuba. Clearly, it is not the number of health professionals that influences child mortality; rather, it must be how those health professionals are organized and what they do that is the influence.Source: Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M et al. Human resources for health: overcoming the crisis. Lancet 2004; 364(9449):*186 countriesStarfield 07/07HS 3754 nSource: Chen et al, Lancet 2004; 364:3

409 Copenhagen general practice May3/23/2017Primary health care is primary care applied on a population level. As a population strategy, it requires the commitment of governments to develop a population-oriented set of primary care services in the context of other levels and types of services.In 1978, the World Health Organization Conference in Alma Ata used the term primary health to characterize an approach to organizing services to meet the needs of populations. Although its focus was derailed by the actions of international organizations such as the World Bank and the International Monetary Fund, which focused more on decentralization and devolving services to local areas to facilitate market solutions rather than government ones, the term primary health care lived on in the minds of many. As the term “primary care” had long been used to describe clinical services provided by family physicians, the distinction between the two became blurred or even used synonymously. The distinction, however is useful, in that the Alma Ata term connotes a population strategy, with the development of policies designed to provide the basis for interventions at the individual level. Thus, primary health care is primary care applied on a population level, with policies designed to facilitate the achievement of primary care for all individuals within the population.Starfield 07/07PC 3755 n4

509 Copenhagen general practice May3/23/2017Primary care is the provision of first contact, person-focused, ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care.On the clinical level, primary care has four main features, all of which must be present in order to define primary care. Sometimes, family orientation and community orientation also are included. Each of these features is measurable, using comparable tools designed for system-level, provider or facility level, patient level, or community level.Starfield 07/07PC 3756 n5

6Why Is Primary Care Important?09 Copenhagen general practice May3/23/2017Why Is Primary Care Important?Better health outcomesLower costsGreater equity in healthThere is now good evidence, from a variety of studies at national, state, regional, local, and individual levels that good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health.Starfield 07/07PC 3757 n6

7International comparisons Population studies within countries 09 Copenhagen general practice May3/23/2017Evidence for the benefits of primary care-oriented health systems is robust across a wide variety of types of studies:International comparisonsPopulation studies within countriesacross areas with different primary care physician/population ratiosstudies of people going to different types of practitionersClinical studiesof people going to facilities/practitioners differing in adherence to primary care practicesSource: Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3):Comparisons of health systems involve two aspects: those that concern the nature of the system and the policies that characterize the system and those that concern the nature of the services themselves. In the comparisons of the primary care orientation of several OECD health systems, 9 characteristics of the system were hypothesized to be related to the primary care orientation of the system, as were 6 characteristics previously identified as related to primary care health services.Starfield 03/08PC 3971 nSource: Starfield et al, Milbank Q 2005; 83:7

8Primary Care Scores, 1980s and 1990s09 Copenhagen general practice May3/23/2017Primary Care Scores, 1980s and 1990s1980s1990sBelgiumFrance*GermanyUnited States0.8-0.50.20.40.3AustraliaCanadaJapan*Sweden1.11.20.9DenmarkFinlandNetherlandsSpain*United Kingdom1.51.71.41.9During the 1990s, two successive international comparisons involved rating different countries on the strength of primary care within the country. Ratings of primary health care were obtained by rating 6 (and 9 in the later study) characteristics of policy in each country: efforts to distribute resources according to where they were most needed; maintaining low or no cost-sharing; financial access controlled or regulated by government; the type of primary care practitioner (family physician or a mixture of types including also general internists and general pediatricians); and the presence of patient lists by primary care practices. In the second study, the following were added: low or no copayments for primary care; strength of academic departments of family medicine; the presence of patient lists by primary care practices; and 24-hour availability of primary care practices. Extent of achievement of the clinical features of first contact care, person-focused care over time, comprehensiveness (breadth) of services, coordination of care, family centeredness, and community orientation were also rated. Each characteristic was rated on a scale of 0 to 2, then all scores were averaged to obtain a systems score, a practice score and a combined overall primary care score. Eleven, and then 13 industrialized countries were compared; this comparison led to three groups of countries: those with low scores, those with intermediate scores, and those with high scores. These three groupings were unchanged over the decade between the two studies.*Scores available only for the 1990sStarfield 07/07ICTC 3758 n8

9Primary Care Orientation of Health Systems: Rating Criteria09 Copenhagen general practice May3/23/2017Primary Care Orientation of Health Systems: Rating CriteriaHealth System CharacteristicsType of systemFinancingType of primary care practitionerPercent active physicians who are specialistsProfessional earnings of primary care physiciansrelative to specialistsCost sharing for primary care servicesPatient listsRequirements for 24-hour coverageStrength of academic departments of family medicineThe predominant form of the health system was rated according to the extent of its primary care orientation in two regards: the strength of health policy conducive to primary care practice and the strength of primary care practice itself.Health policy characteristics concerned to the extent to which there are efforts to distribute health services resources equitably in the population, the aegis and universality of financing for primary care, whether the modal primary care practitioner was a family physician, the balance between the number of primary care physicians and specialists as well as the amount of their professional remuneration, the absence of cost sharing for primary care services, requirements for the maintenance of patient rosters or lists, the extent of requirements for 24-hour coverage, and the strength of academic departments of family medicine. Each country was given a score of 0, 1, or 2 depending on how strongly the characteristic was developed.Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.Starfield 11/02PC 2366 nStarfield 11/02sc9

10System Features Important to Primary Health Care09 Copenhagen general practice May3/23/2017System Features Important to Primary Health CareResource Allocation (Score)Progressive Financing*Cost SharingCompre-hensivenessBelgiumFranceGermanyUS12AustraliaCanadaJapanSwedenDenmarkFinlandNetherlandsSpainUK***0=all regressive1=mixed2=all progressive**except MedicaidThis slide shows the four main policy characteristics related to effectiveness and equity of primary health care services: distribution of resources according to extent and type of health needs, progressivity of financing, degree of cost sharing, and breadth of services provided in primary care. Scores range from zero (0), where the policy characteristic is absent, to a score of 1, where the characteristic is present but poorly developed, to a score of 2, where the characteristic is well developed. Belgium, France, Germany, and the US have weak primary health care systems; Denmark, Finland, The Netherlands, Spain, and the UK have strong primary healthcare; and Australia, Canada, Japan, and Sweden are in-between. With few exceptions, countries with equity-focused health policy are countries with strong primary care; countries with weak policy characteristics have weak primary care health systems.Sources:Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.van Doorslaer E, Wagstaff A, Rutten F. Equity in the Finance and Delivery of Health Care: An International Perspective. New York: Oxford University Press, 1993.Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, van Doorslaer et al. Equity in the Finance and Delivery of Health Care: An International Perspective. Oxford U. Press, 1993.Starfield 11/06EQ 3500 n10

11Universal financial coverage, under governmental control or regulation 09 Copenhagen general practice May3/23/2017Key system factors in achieving primary health care in both developing and industrialized countries are:Universal financial coverage, under governmental control or regulationEfforts to distribute resources equitably (according to degree of need)No or low co-paymentsComprehensiveness of servicesBoth international comparisons and within-country studies provide the basis for specifying 6 key factors in achieving an effective health system (Starfield and Shi 2002; Gilson et al 2007). There are some countries in the world that approach the achievement of these policies; they also have the best health in the world, as measured by conventional and widely accepted health statistics, including mortality and illness rates as well as indicators related to death and age at death.Sources:Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):Gilson L, Doherty J, Loewenson R, Francis V. Challenging Inequity through Health Systems. Final Report, Knowledge Network on Health Systems, June WHO Commission on the Social Determinants of Health. (http://www.who.int/social_determinants/resources/csdh_media/hskn_final_2007_en.pdf; accessed March 17, 2009) Johannesburg, South Africa: Centre for Health Policy, EQUINET, London School of Hygiene and Tropical Medicine, 2007.Sources: Starfield & Shi, Health Policy 2002; 60: Gilson et al, Challenging Inequity through Health Systems (http://www.who.int/social_determinants/resources/csdh_media/hskn_final_2007_en.pdf; accessed March 17, 2009).Starfield 07/07GH 3794 n11

13Primary Care Orientation of Health Systems: Rating Criteria09 Copenhagen general practice May3/23/2017Primary Care Orientation of Health Systems: Rating CriteriaPractice CharacteristicsFirst-contactPerson-focus over timeComprehensivenessCoordinationFamily-centerednessCommunity orientationEach country was also rated 0, 1, or 2 with regard to its achievement of the cardinal features of primary care practice. A score of 0 indicates poor achievement of the feature; a score of 1 indicates intermediate achievement, and a score of 2 indicates high achievement of the feature.First contact is the seeking of care for each newly occurring problem or need from a primary care practitioner rather than a specialist. Longitudinality is person-focused (not disease-focused) relationships over time with the primary care source. Comprehensiveness is the provision, by the primary care source, of services for all health-related needs except those too uncommon in the population for competence to be maintained. Coordination is the integration of care by the primary care source when services outside of primary are required.Two related characteristics were also rated. Family centeredness is the extent to which services are provided in a family context. Community orientation is the extent to which data on community health needs are taken into account in planning for primary care services.Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.Starfield 04/09PC 4180 n13

1509 Copenhagen general practice May3/23/2017System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990sUKNTHSPFINCANAUSSWEJAPGERFRBELUSDKThe primary care score has two parts: the first reflects the strength of primary health care (that is, policies oriented towards primary care), and the second reflects the practice of primary care at the clinical level. In this chart, the countries are ranked by each of their two sub-scores. The country with the best sub-score is ranked #1, and the one with the worst sub-score is ranked #13. The better the policies (systems rankings), the better the practices, indicating the importance of governmental policy to good practice.Based on data in Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):*Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance.Starfield 03/05ICTC 3099 nBased on data in Starfield & Shi, Health Policy 2002; 60:15

16Primary Care Score vs. Health Care Expenditures, 199709 Copenhagen general practice May3/23/2017Primary Care Score vs. Health Care Expenditures, 1997UKDKNTHFINSPCANAUSSWEJAPAn international comparison of industrialized nations found a statistically significant relationship between per capita health care expenditures and the extent to which the health system was oriented around strong primary care policies and practices*. The stronger the primary care, the lower the total health care expenditures. This was the case even when the United States, with its high expenditures and poor primary care infrastructure, was removed from the analysis.*according to the method described in Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press, 1998, chapter 15.GERUSBELFRStarfield 11/06ICTC 3495 n16

17Primary Care Strength and Premature Mortality in 18 OECD Countries09 Copenhagen general practice May3/23/2017Primary Care Strength and Premature Mortality in 18 OECD CountriesYearHigh PC Countries*Low PC Countries*10000PYLL19701980199020005000In an international comparison of 18 OECD countries, they were rated* according to whether their primary care systems were strong (high scores) or weak (low scores). Trends in potential years of life lost were examined after also taking into account other influences on health. Even after considering changes in gross domestic product, percentage of elderly people, total number of doctors per capita, average income, and smoking and drinking percentages, people in countries with strong primary care had fewer years of life lost than people in the poor primary care countries, and the differences widened over time.*according to the method described in Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press, 1998, chapter 15.Source: Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, Health Serv Res 2003; 38(3):*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.Starfield 11/06IC 3496 nSource: Macinko et al, Health Serv Res 2003; 38:17

18Primary Care Oriented Countries Have09 Copenhagen general practice May3/23/2017Primary Care Oriented Countries HaveFewer low birth weight infantsLower infant mortality, especially postneonatalFewer years of life lost due to suicideFewer years of life lost due to “all except external” causesHigher life expectancy at all ages except at age 80These indicators of health system “outcome”, included low birth weight, neonatal mortality, postneonatal mortality, years of life lost associated with suicide, with all-cause mortality excluding external causes such as injuries, and higher life expectancy at all ages (birth, age 15, age 40, and at age 65, but to a much lesser degree at age 80.Sources:Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press, 1998.Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, Starfield & Shi, Health Policy 2002; 60:Starfield 07/07IC 3762 n18

1909 Copenhagen general practice May3/23/2017The global imperative is to organize health systems around strong, patient-centered, i.e., Primary Care.A disease-by-disease approach will not address the most serious shortfall in achieving the health-related Millennium Development Goals. It will also worsen global inequities. Those exposed to a variety of interacting influences are vulnerable to many diseases. Eliminating diseases one by one will not materially reduce the chances of others.Sources:IBRD/World Bank, April 8, 2008.King CH, Bertino AM. Asymmetries of poverty: why global burden of disease valuations underestimate the burden of neglected tropical diseases. PLoS Negl Trop Dis 2008;2:e209.Sources: IBRD/World Bank, April 8, King & Bertino, PLoS Negl Trop Dis 2008;2:e209.Starfield 03/08GH 399219

2009 Copenhagen general practice May3/23/2017Is Primary Care as important within countries as it is among countries?Given the robust findings of the superiority of primary care-orientation across countries, it was of interest to learn whether the same could be said of differences within countries.Starfield 07/07WC 3765 n20

21State Level Analysis: Primary Care and Life Expectancy09 Copenhagen general practice May3/23/2017State Level Analysis: Primary Care and Life ExpectancyMENHVTMARICTNYNJPAOHINILMIWIMNIAMONDSDNEKSDEMDVAWVNCSCGAFLKYTNALMSARLAOKTXMTIDWYCONMAZUTNVWAORCAAKHIThis analysis examined the relationship between the ratio of primary care physicians to population against life expectancy in every state in the United States. Although there are a few states that show considerable deviation from the general relationship, it is clear that, in general, the greater supply of primary care physicians is associated with higher life expectancy. Each additional primary care physician is associated with an increase of over a year of life expectancy, on average.Source: Shi L. Primary care, specialty care, and life chances. Int J Health Serv 1994;24:Starfield 04/09WCUS 4178 nSource: Shi, Int J Health Serv 1994;24:21

22Primary Care and Infant Mortality Rates, Indonesia, 1996-200009 Copenhagen general practice May3/23/2017Primary Care and Infant Mortality Rates, Indonesia,Primary care spendingper capita*10.39.68.58.2Hospital spending4.14.44.65.3Infant mortality20% improvement(all provinces)( )14% worsening(22 of 26 provinces)Well designed primary care services have been demonstrated to improve health, even in developing and middle income countries that have pursued their development. In Indonesia, spending on primary care increased in the early 1990s, reaching 10.3 billion Indonesian rupiah in 1996 and accomplishing a 20% improvement over five years in infant mortality  improvement in every province in the country. Hospital spending at this time was 4.1 billion rupiah. In the subsequent five years, primary care spending per capita was progressively reduced, reaching 8.2 billion rupiah, concomitant with a rise in hospital spending per capita from 4.1 to 5.3 billion rupiah. During this period, infant mortality rose in 22 of the 26 provinces, with a 14% rise in the country as a whole.Source: Simms C, Rowson M. Reassessment of health effects of the Indonesian economic crisis: donors versus the data. Lancet 2003; 361(9366):*constant Indonesian rupiah, in billionsSource: Simms & Rowson, Lancet 2003; 361:Starfield 07/07WC 3796 n22

2409 Copenhagen general practice May3/23/2017Impact of PSF Coverage on Infant Mortality in Brazilian States, : Marginal Effects*Source: Macinko J, Guanais FC, de Fatima M, de Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, J Epidemiol Community Health 2006; 60(1):13-19.In Brazil, primary care reform has been spreading throughout the country since the early 1990s. As a very sensitive indicator of the effectiveness of health systems, infant mortality was chosen to evaluate the impact of this reform process. This evaluation took into consideration other changes that might be expected to influence infant mortality over the period of the primary care reform. In evaluating the relative roles of the different changes, the importance of decreasing the illiteracy of women was highlighted, with 15% of the decline in infant mortality attributed to it. The second most influential change was the implementation of the primary care reform (“PSF coverage”), which accounted for almost 5% of the decline. Of lesser importance were increasing availability of clean water (about 3%), decreased fertility rates (about 2%), and the number of hospital beds (about 1%). These characteristics alone accounted for 90% of the variability in infant mortality rates across the Brazilian states. Of no demonstrable importance in influencing the decline in infant mortality were physician and nurse supply. That is, the number of health personnel is not of importance to health outcomes; rather, it is what these professionals do that is the determining characteristic.*Based on 2-way fixed effects model of Brazilian states, , n=351 R^2=0.90. Non-significant (p>0.05) control variables, including physician and nurse supply and sewage not shown.Starfield 10/06WC 3457 nSource: Macinko et al, J Epidemiol Community Health 2006; 60:13-19.24

27Does primary care reduce inequity in health?09 Copenhagen general practice May3/23/2017Does primary care reduce inequity in health?The preceding empirical demonstrations of the influence of a primary care orientation show that it is associated with greater effectiveness of health services. Does primary care also improve equity in health?Starfield 07/07EQ 3769 n27

2809 Copenhagen general practice May3/23/2017In the United States, an increase of 1 primary care doctor is associated with 1.44 fewer deaths per 10,000 population. The association of primary care with decreased mortality is greater in the African-American population than in the white population.As the effect of increasing primary care health professionals is greater in more deprived populations (in this case, the African American population in the US), it can be said that primary care is equity-producing.Source: Shi L, Macinko J, Starfield B, Politzer R, Xu J. Primary care, race, and mortality in US states. Soc Sci Med 2005; 61(1):65-75.Starfield 07/07WCUS 3770 nSource: Shi et al, Soc Sci Med 2005; 61(1):65-75.28

29Percentage Reduction in Under-5 Mortality: Thailand, 1990-200009 Copenhagen general practice May3/23/2017Percentage Reduction in Under-5 Mortality: Thailand,Poorest quintile (1)44(2)41(3)22(4)23Richest quintile (5)13Rate ratio (Q1/Q5)55Absolute difference (Q1-Q5)61Policy changes:1989At least one primary care health center for each rural village1993Government medical welfare scheme: all children less than 12, elderly, disabled2001Entire adult population insuredActivities of Rural Doctors’ SocietyDuring the 1990s, policy in Thailand led to the development of at least one primary care health center in each rural village. During this time period, insurance for medical services was progressively expanded to cover the entire population by the early 2000s. A very active Rural Doctors Society was a major advocate of this expansion. During this period, under-5 mortality was lowered by a much greater percentage in more deprived populations than in less deprived ones: 44% in the poorest quintile and 13% in the richest percentile  with a progressively greater reduction in successive percentiles of wealth. Both relative and absolute differences in under-5 mortality were reduced.Source: Vapattanawong P, Hogan MC, Hanvoravongchai P et al. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet 2007; 369(9564):Starfield 07/07WC 3797 nSource: Vapattanawong et al, Lancet 2007; 369:850-5.29

3409 Copenhagen general practice May3/23/2017ConclusionAlthough sociodemographic factors undoubtedly influence health, a primary care oriented health system is a highly relevant policy strategy because its effect is clear and relatively rapid, particularly concerning prevention of the progression of illness and effects of injury, especially at younger ages.Starfield 11/05HS 332934

35Strategy for Change in Health Systems09 Copenhagen general practice May3/23/2017Strategy for Change in Health SystemsAchieving primary careAvoiding an excess supply of specialistsAchieving equity in healthAddressing co- and multi-morbidityResponding to patients’ problemsCoordinating careAvoiding adverse effectsAdapting payment mechanismsDeveloping information systems that serve care functions as well as clinical informationThis slide summarizes the conclusions of many studies. The following slides provide specificity for each one.Starfield 11/06HS 3494 n35

3709 Copenhagen general practice May3/23/2017In 35 US analyses dealing with differences between types of areas (7) and 5 rates of mortality (total, heart, cancer, stroke, infant), the greater the primary care physician supply, the lower the mortality for 28. The higher the specialist ratio, the higher the mortality in 25.Above a certain level of specialist supply, the more specialists per population, the worse the outcomes.The poorer health outcome when specialist supply is very high is robust, and is found for different causes of mortality in different types of geographic areas.Source: Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The relationship between primary care, income inequality, and mortality in US States, J Am Board Fam Pract 2003; 16(5):Controlled only for income inequalitySource: Shi et al, J Am Board Fam Pract 2003; 16:Starfield 11/06SP 3499 n37

38Percentage of People Seeing at Least One Specialist in a Year09 Copenhagen general practice May3/23/2017Percentage of People Seeing at Least One Specialist in a YearUS40% of total population; 54% of patients (users)Canada(Ontario)31% of population (68% at ages 65 and over)UKabout 15% of patients (at ages under 65)Spain30% of population; 40% of patients (users)The seeking of care from specialists varies considerably across different health systems. In some countries, e.g., the United States, it is common for patients to go directly to a secondary care physician (specialist) without a referral from another health professional (usually a primary care physician). In at least some parts of Canada, self-referrals are discouraged, as specialists are paid a lower fee in such instances. In the UK and Spain, seeing a secondary care physician through a referral from primary care is the norm in the national health system.The percentage of patients seeing one or more specialists in a year in the United States is very high (at least 40% of the population, but over half of people who have sought any care) but very variable, and it is much higher among the elderly, reaching to over 90% in some health care organizations. In Canada and Spain, the percentage is less and in the UK is about half of that in these two countries – about 15% in the non-elderly. The extent to which the excess in the US is a result of increased self-referral, poor comprehensiveness of primary care, historical practice and peoples’ expectations, and/or financial incentives that encourage specialty care is unknown.Whatever the explanation, the subject of the role of specialists deserves investigation. In view of the evidence that much of specialty care may be inappropriate and increasing,1 and that it raises costs of care unnecessarily, studies of the contributions made by specialists to diagnosis and management are needed, as are studies of the role of primary care in maintaining comprehensiveness of services in the primary care sector. Increasing comprehensiveness of care is associated with more effective, efficient, and equitable services in countries where the subject has been studied.21Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing the evidence. Health Aff 2005; W5: Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):Sources: Peterson S, AAFP (personal communication, January 30, 2007). Jaakkimainen L, Upshur REG, Klein-Geltink JE et al. Primary Care in Ontario. ICES Atlas. Toronto, CA: Institute for Clinical Evaluative Sciences, Sicras-Mainar A, Serrat-Tarres J, Navarro-Artieda R, Llausi-Selles R, Ruano-Ruano I, Gonzalez-Ares JA. Adjusted Clinical Groups use as a measure of the referrals efficiency from primary care to specialized in Spain. Eur J Public Health 2007; 17(6): Starfield B, Chang H-Y, Lemke KW, Weiner JP. Ambulatory specialist use by non-hospitalized patients in US health plans: correlates and consequences. Submitted 2008.Sources: Peterson S, AAFP (personal communication, January 30, 2007). Jaakkimainen et al. Primary Care in Ontario. ICES Atlas. Toronto, CA: Institute for Clinical Evaluative Sciences, Sicras-Mainar et al, Eur J Public Health 2007; 17: Starfield et al, submitted 2008.Starfield 01/07SP 3529 n38

39Resource Use, Controlling for Morbidity Burden*09 Copenhagen general practice May3/23/2017Resource Use, Controlling for Morbidity Burden*More DIFFERENT specialists seen: higher total costs, medical costs, diagnostic tests and interventions, and types of medicationMore DIFFERENT generalists seen: higher total costs, medical costs, diagnostic tests and interventionsMore generalists seen (LESS CONTINUITY): more DIFFERENT specialists seen among patients with high morbidity burdens. The effect is independent of the number of generalist visits. That is, the benefits of primary care are greatest for people with the greatest burden of illness.Source: Starfield B, Chang H, Lemke KW, Weiner JP. Ambulatory specialist use by non-hospitalized patients in US health plans: correlates and consequences. J Ambul Care Manage 2009 forthcoming.*Using the Johns Hopkins Adjusted Clinical Groups (ACGs)Source: Starfield et al, Ambulatory specialist use by patients in US health plans: correlates and consequences. J Ambul Care Manage 2009 forthcoming.Starfield 09/07CMOS 385439

4009 Copenhagen general practice May3/23/2017Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two YearsCountryOne doctor4 or more doctorsAustralia1237Canada1540Germany1431New Zealand35UK28US2249Source: Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh J, Davis K. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Affairs 2005; W5:Seeing a large number of different physicians, including specialists, is potentially dangerous for people. This chart shows that a much larger percentage of people in the US have seen four or more doctors in the most recent two years. Increased frequency of adverse events is at least partly a result of the prescription of large numbers of medications, some of which are very powerful recent additions to the armamentarium of available medications. These new medications have relatively high unintended effects.1 As the frequency of adverse events rises with increasing number of physicians seen, the practice of frequent referrals and self-referrals to specialists is likely to be detrimental to health,2-3 particularly in view of evidence that inappropriate specialty care often is associated with worse health.4-51Avorn J. Dangerous deception--hiding the evidence of adverse drug effects. N Engl J Med 2006; 355(21): Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in 'case' management. Ann Fam Med 2003; 1(1): Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med 2005; 3(3): Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing the evidence. Health Aff 2005; W5: Starfield B, Chang H-Y, Lemke KW, Weiner JP. Ambulatory specialist use by non-hospitalized patients in US health plans: correlates and consequences. Submitted 2008.Starfield 09/07IC 3870 nSource: Schoen et al, Health Affairs 2005; W5:40

4709 Copenhagen general practice May3/23/2017The impact of a health services intervention should not be evaluated on the basis of a structural element of health systems alone. The value of health system structures lies only in the behaviors that they engender. In order to understand why and how things have an impact, it is necessary to evaluate the impact of structures on processes of care. That is why evaluations of structures such as type or number of practitioners, electronic health records, and the Chronic Care Model (CCM) have inconsistent results.Starfield 10/08EVAL 407247

48The Health Services System09 Copenhagen general practice May3/23/2017The Health Services SystemLongevityComfortPerceived well-beingDiseaseAchievementRisksResilienceCAPACITYPERFORMANCEHEALTH STATUS(outcome)Provisionof careReceiptPersonnelFacilities and equipmentRange of servicesOrganizationManagement and amenitiesContinuity/information systemsKnowledge baseAccessibilityFinancingPopulation eligibleGovernancePeople/practitioner interfaceCultural andbehavioralcharacteristicsSocial, political,economic, and physical environmentsBiologic endowmentand prior healthProblem recognitionDiagnosisManagementReassessmentUtilizationAcceptance and satisfactionUnderstandingParticipationCommunity resourcesSource: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.This figure specifies the important components of health services systems according to their type (structure, process, and outcome in the terminology of Donabedian (1966). In the diagram, structural components of health services systems are designated as Capacity and include the characteristics that enable medical practices to provide services. The process components are designated as Performance and include the categories of action engaged in by practitioners as well as the actions of patients and populations that enable them to receive services that are recommended. All characteristics of health systems and their interactions with communities and civil society should be represented by this diagram. (The diagram applies to ambulatory care as well as to care in institutions; hospitalization is represented as a management strategy under the control of providers.) Costs can be superimposed on each of the components of the system. Donabedian A. Evaluating the quality of medical care. Milbank Q 1966; 44(3, pt 2):Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.Starfield 02/09HS 4133 n48

50Primary Care Scores by Data Source, PSF Clinics09 Copenhagen general practice May3/23/2017Primary Care Scores by Data Source, PSF ClinicsFirst ContactResources AvailableSource: Almeida C & Macinko J. Validação de uma Metodologia de Avaliação Rápida das Características Organizacionais e do Desempenho dos Serviços de Atenção Básica do Sistema Único de Saúde (SUS) em Nível Local [Validation of a Rapid Appraisal Methodology for Monitoring and Evaluating the Organization and Performance of Primary Health Care Systems at the Local Level]. Brasília: Pan American Health Organization, Office of Technical Cooperation in Brazil, 2006.The data in this “spider’s web” depict the achievement of the essential features of primary care in primary care practices in an area of Brazil. It also shows the considerable agreement between the three sources of information: patients, practitioners, and managers in the facilities. A score of five represents the maximum, with a score of zero representing the minimum possible. Whereas the facilities scored high on the range of services available (“resources available”) and on a family focus of the health services, scores were relatively low for accessibility of the services. This study showed the potential for application of a standardized and validated instrument (the PCAT) to assess the quality of delivery of primary care services, from the viewpoint of users, providers, and managers. In this way, possible improvements can be discussed and implemented.Source: Almeida & Macinko. [Validation of a Rapid Appraisal Methodology for Monitoring and Evaluating the Organization and Performance of Primary Health Care Systems at the Local Level]. Brasília: Pan American Health Organization, 2006.Starfield 05/06WC 3421 n50

5209 Copenhagen general practice May3/23/2017There is no such thing as a “primary care service”. There are only primary care functions and “specialty care” functions. We know what the primary care functions are; they are evidence-based. Payment should be based on their achievement over a period of time. Any payment system that rewards specific services will distort the main purpose of medical care: to deal with health problems effectively, efficiently, and equitably.Starfield 06/08PC 404652

53Primary Care First Contact Accessibility09 Copenhagen general practice May3/23/2017Primary CareFirst ContactAccessibilityUse by people for each new problemLongitudinalRelationship between a facility and its populationUse by people over time regardless of the type of problem; person-focused character of provider/patient relationshipComprehensiveBroad range of servicesRecognition of situations where services are neededCoordinationMechanism for achieving continuityRecognition of problems that require follow-upPrimary care has four main functions: first contact (the place where care is first sought for a new or newly recurring health problem or health need); longitudinality (person-focused care over time); comprehensiveness (providing for all common health needs without referral); and coordination (integrating all aspects of care when people have to go elsewhere for uncommon or unusually serious health conditions). Each of these four essential functions can be described and assessed by using several of the elements of health systems, as described in this chart.Starfield 02/08EVAL 3968 n53

5409 Copenhagen general practice May3/23/2017Structural and Process Elements of the Essential Features of Primary CareCapacityEssential FeaturesPerformanceAccessibilityEligible populationRange of servicesContinuityFirst-contactUtilizationPerson-focusedrelationshipLongitudinalityComprehensivenessThis diagram shows how just seven elements are used to describe and measure the four essential functions of primary care. Each function entails the achievement of a particular structural element that the practitioner or practice must have in place in order for there to be appropriate performance. Three aspects of performance are important to the achievement of the function. For two of the functions (comprehensiveness and coordination), that element is the recognition of patients’ problems. For a service to be comprehensive, the totality of a patient’s health problems must be recognized in order for appropriate actions to be taken. For coordination, the practitioner or facility needs to recognize which problems require integration into the totality of care provided to the patient in order to achieve effective and safe care.Problem recognitionCoordinationStarfield 04/97EVAL 1108 nStarfield 199797-19454

5509 Copenhagen general practice May3/23/2017Structural and Process Elements of the Essential Features of Primary CareCapacityEssential FeaturesPerformanceAccessibilityEligible populationRange of servicesContinuityFirst-contactUtilizationPerson-focusedrelationshipLongitudinalityComprehensivenessThis diagram shows how just seven elements are used to describe and measure the four essential functions of primary care. Each function entails the achievement of a particular structural element that the practitioner or practice must have in place in order for there to be appropriate performance. Three aspects of performance are important to the achievement of the function. For two of the functions (comprehensiveness and coordination), that element is the recognition of patients’ problems. For a service to be comprehensive, the totality of a patient’s health problems must be recognized in order for appropriate actions to be taken. For coordination, the practitioner or facility needs to recognize which problems require integration into the totality of care provided to the patient in order to achieve effective and safe care.Problem recognitionCoordinationStarfield 10/08EVAL 4071 n55